Healthcare Provider Details

I. General information

NPI: 1144295551
Provider Name (Legal Business Name): JOHNS CREEK ENT PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4045 JOHNS CREEK PKWY SUITE C
SUWANEE GA
30024-1253
US

IV. Provider business mailing address

4045 JOHNS CREEK PKWY SUITE C
SUWANEE GA
30024-1253
US

V. Phone/Fax

Practice location:
  • Phone: 770-495-7116
  • Fax:
Mailing address:
  • Phone: 770-495-7116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0901X
TaxonomyOtology & Neurotology Physician
License Number042452
License Number StateGA

VIII. Authorized Official

Name: FERMIN V STEWART
Title or Position: DOCTOR
Credential: M.D.
Phone: 770-495-7116